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2023 HSR&D/QUERI National Conference Abstract

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1090 — Stakeholder perspectives on supporting Veterans’ social needs during hospital to home health transitions: Findings from the Transitions Nurse Program

Lead/Presenter: Marguerite Daus,  COIN - Seattle/Denver
All Authors: Daus MM (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System), Lee M (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System) Albright K (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, University of Colorado Anschutz Medical Campus) Holstein A (Pitkin County Public Health) McCarthy M (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System) Ayele R (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, University of Colorado Anschutz Medical Campus) Ujano-De Motta LL (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System) Morgan B (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System) Sjoberg H (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System) Jones CD (Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, University of Colorado Anschutz Medical Campus)

Objectives:
Veterans have unique needs related to their military service that may exacerbate their risk for adverse clinical outcomes. Veterans’ social needs (e.g., access to healthy food, housing, transportation) are particularly understudied, affecting their ability to access care and safely transition from hospital to home. To understand these factors, we sought to explore the barriers and solutions to meeting social needs experienced by Veterans during the transition from hospital to home with home healthcare (HHC).

Methods:
Qualitative data were collected through individual interviews with stakeholders who have significant roles facilitating Veterans’ hospital to HHC transition (VA and HHC staff/clinicians, Veterans, caregivers). Participants were asked about care coordination between VA and HHC staff/clinicians and the social needs of Veterans during their transition from hospital to HHC. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis with ATLAS.ti 9.0.

Results:
We conducted 21 interviews at 4 VA Medical Centers (VAMCs) with 5 Veterans/caregivers who recently transitioned from hospital to home, 4 HHC staff/clinicians from VAMC affiliated HHC agencies, and 12 VA staff/clinicians. The social ecological framework was used to guide the analysis to understand barriers and solutions for facilitating effective social needs management in the hospital to HHC transition. Five system-level themes emerged: 1) Additional tools needed: VA and HHC stakeholders felt they would benefit from additional resources to assess and address social needs including a community resource referral system; 2) Staff capacity: VA and HHC stakeholders described that limited staffing leads to missed opportunities, which could be addressed by dedicated staff for care coordination and social needs management; 3) Interagency communication: HHC clinicians reported that they lack the ability to report social needs to VA clinicians, resulting in unmet social needs and a desire for closed-loop communication pathways between VA and HHC; 4) VA policy affecting Veteran care: all sites reported that VA policies affected Veterans’ ability to receive health services or access care in a timely manner and proposed that policies should be assessed and improved to facilitate high-quality Veteran care; 5) Social Determinants of Health (SDOH) integration: few stakeholders received information on SDOH and existing resources for social needs management which indicated a need for SDOH integration into VA education. In addition to these system-level themes, data revealed insights about individual-level factors contributing to social needs for Veterans discharged to HHC: access/affordability of care, social support, health literacy, home environment, and rurality.

Implications:
As a national, integrated health care system, the VA is uniquely positioned to work with HHC agencies to detect and address Veterans’ social needs. All barriers detected in this analysis highlight the need to identify solutions at both individual- and system-levels across VA and HHC systems. Given the variability of resources and knowledge in the VA, integration of the SDOH into VA culture by incorporating awareness of SDOH into trainings should be the first step in solution development.

Impacts:
This exploratory study identified barriers and solutions for facilitating effective social needs management in the hospital to HHC transition by highlighting focus areas for VAMCs to improve Veteran care.